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Home My WebLink AboutSEP1974-00151Jefferson County Department of Comr 621 Sheridan St., Port Townsend WA Also known as Draw on the back of this sheet a cur Buildings, Drainftelds, Septic Tanks, identifying these items. ALL SPACES MUST BE FILLED IN. If Type of Evaluation VEvaluation of on-site sewage system ❑ Evaluation of drinking water ❑ Evaluation of on-site sewage & drinking Date of evaluation 3 - 3 ! _ t Tax Parcel #__ � "" 6 - �' c, ! ..�L Pen Subdivision, Division, Block and Lot(s) Lot Size Acres or Dimensic Current Owner C �� ✓ Site Address Owner Phone # Previous property owner name(s) - (N Directions to Site �G ;"0/7' 1o,-0SCnQ /f CLQ Date System Installed /U 7Z - House Occupied._ -yes Who installed system? ` ry Send completed report to: Owner Name Mailing Address Phone/email/fax Realtor or Other Representative Name Mailing Development B (360) 379-4450 an Existing Onsite Sewage System (EES) plot plan showing location of. Is, etc OR attach a current plot plan Office Use Only Date_ -::E-1y — Fee i _C% do Recpt_ 17 Sl2 Check. 071 Case # 7q- - 15 =� is not available enter (NV) or not applicable (NA). Reason for Evaluation 0 Routine Operation and Monitoring Inspection ❑ Real Estate transaction ,,rr�� j Complete a Permit # ✓✓ ) D ❑ Building Permit Review and/or no septic permit on file ❑ Other, explain Inspected by °, ,ti 0 �I! l� f System /yes no Permit/case # SEP7y4-�� % -, c�'„✓✓rr'.rr�A / vis if not known) A/ c��133/ C- c � Age of Dwelling 3C -# Bedrooms _ io, vacant h w long? Phone/email/fax H:1wE8X0NSITEk0-M12009 Onsite inspection Form 11-2 9 Page 1 of 4 Include the following items on your i Property boundaries a Names of adjacent streets Driveways and parking spaces o Surface water (ponds,creeks, e &r/'Buildings(residence, sheds, ga PLOT PLAN -date z�� -3 r to plan: , etc) /"-) �(. C / Ij�,;'r � n G Dr; ✓�, W Li Wells 0Septic tank W/ Drainfield (enter NN if unknown) North Arrow CC, 45- S1rr1el Page 2 of 4 Permft # or Parcel # 7 ( Monitoring Inspection - E Date of Inspection -3 .3 /- of an Existing Onsite Sewage System Inspected by_ Water Supply (fill in only if Ovate pR1 is being tested in this evaluation) Sample was taken a No Sample Results Well casing 12" ove oun Yes No Sanitary Seal i place Yes No Public: ff ' Ite Name of System Individual: offsite onsite Is well more th ' drainfi Id/disposal component _yes_ no, if not, distance Is well more than 50' to tanks a id effluent transport line „_yes_ no, if not, distance ONSITE SEWAGE SYSTEM # Bedrooms/gallons per day indicated in County Health Dept. records for this caseV #1 - Septic Tank Tank size 0 Cts gal. Riser to grade on inlet to Condition of tank good 1st comp."Scum (top layer)_ 2nd comp. scum in. slu Was ground water observed leaking into tank ? If yes, where was water Condition of baffles. Inlet: 11� Outlet: Screened Outlet Septic tank needs to be pumped Effluent level at outlet (mark level on circle) ( eg: 9 ) tment two compartment material no. Riser to grade on outlet �es no seeds repair, describe n. sludge (b ttom layer) in. le Alin. yes V no needs repair material (PVC,Concrete) _needs repair V C, material (PVC,concrete) no _yes, condition clean clogged/dirty Jefferson County code 815.150 (1) (b�) v/ yes no C' �� .3 If effluent is below the outlet, indicate when tank was last pumped: Does system include a pump? yes If lyes, complete the next section V no (if no skip to section 3) #2 Pump Chamber Tank size gal. Material. Riser to grade? yes 1110 Condition of tank clood needs repair, describe Solids in Tank (see 8.15.150 ®yes no scum in. sludge in. Was Ground water obs If yes, where Screen around pump Shroud around pump. Electrical Components Pump operating High water alarm functions Elec. Panel condition Pump cycle drawdown Timer Settings min/sec on Monitoring Inspection - Evalu; Permit # or Parcel yes no condition clean _ dirty/clogged no, describe no, if no, describe needs repair, describe Time for pump cycle min/sec. min/hrs off Floats secured: yes.no of an Existing Onsite Sewage System Page 3 of 4 #3-- Drainfieid Appropriate Vegetation in area ti/ yes Indications of surfacing sewage (check one) Signs of parking/driving in area Ground settling or erosion Monitoring Port Observations (if present): Residual Head ves. Ponding in trench IV„VY , _ Repair area is? Available as shown on Addendum is attached for evaluation of Tre, COMMENTS (attach additional sheet if neci At i- a V, eld //� 0 0 TS Describe vegetation'' if yes, describe and diagram on plot plan area is overgrown and not observable no drainfield area unknown 7—no overgrown/not observable # of inches no # of inches of ponded effluent no ��Z None evaluated or shown on permit Unit or detailed evaluation of drainfield _yes.�l no f e d” L e Was a System Problem Identified? Yes if yes, what section #. No This report on the existing onsite sewage systern is valid for the permitted or historic (if installed prior fo permit requirements) use of the system only and does not constitute assurance of future County approvals (such as building permits) on this parcel. Any future application will be judged separately by the rules and laws in effect at that time. I certify that the information provided is based inspection. ®'? /-'s4 , , 1 No guarantee of future onsite sewage system F this report. This report constitutes a summary Permit # or Parcel # e( i a review of County records and my direct observations at the time of Date erformance is implied or granted based on the information contained in )f findings only. Paged of 4 903 E. Caroline Port Angeles Court House r' Port Townsend f _._A OLYMPIC HEALTH DISTRICT Permit No. SEWAGE DISPOSAL PERMIT APPLICATION Submit.n Duplicate, Builder nate !� DIRECTIONS FOR LOCATING SITE APPLICATION IS HEPMY MADE M INST I SYST�REPAIR EXISTING SYSTEM VDl4STTT TTAi/7 ATYI AT.I T1 Tz11T I^/1w a_ r • r. w�.rw-wxn" rwn� n an _. 11TAwrt'1"riTn `TAT['r R1'G T T I LEND " 1,IID !� TH l SEPTIC TANK SIZE DRAW A DETAILED PLOT PLAN B W. S UCTIONS. SOIL TYPE a � ' CHANGE IN BUIOR S • AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES TKIS PERMIT UNLESS PRIOR APPROVAL OBTAINED FRRM THE HEALTH DEPA � I/ � DATE OF INSTALLATION SIGNATURE OF APPLICANT APPROM �� DATE INSPECTED BY_ �\ ,�� SANITARIAN'S CO11MENTS : -`- I CERTIFY THAT THIS HEALTH DEAPRTMENT TALLED IN THE MANNER APPROVED BY THE 0 C�\ So JEFFERSON COUNTY PERMIT CENTER ve' `""'�"''�►cetw OTH # 621 SHERIDAN �,� RECEIPT! 9" 206-379-4450 PORT D WA 98368 DATE— /l,C2�i�2 CA CHECK0! SSP �� EVALUATION OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR WATER SUPPLY Information Requested: � Individual Sewage Disposal System t 1 _ Water Supply Applicant's Name Applicant's Address Applicant's Phone'Z Z - g;. 2-2 Owner's Name 5g:Med Owner's Address Public Private Mail Completed Report To: Owner's Phone Previous Owner (if known) Occupied? Vacant ,vo` How long? c Number of Bedrooms Year Installed i c 7 Site Address: t l Legal ' Description: Section Plat Name:.?a1t1`y7 Parcel No. L1,5/1(' -D6 90-7 Directions to -property Attach oli Township N, Range Block/Division kuk5L Lot 2• - Permit # showing location of structures, drainfield & septic tank. FOR HEALTIf DEPARTMENT USE ONLY - DO NOT WRITE BELOW THIS LINE SEWAGE DISPOSAL SYSTEM* Permitted system yes no Installed prior to permit requirement? yes -z no Swage noted on ground at time of inspection* �..- House is unoccupied therefore an evaluation o rarnfield perrorman a Is not pos ible at this time. Health Department records indicate that this system was designed to service a obedroom residence. Septic tank should be pumped if not done within past 3 - 5 years. Septic tank: ►oan volume 1 compartment 2 compartment Baffles: good condition inlet missing outlet missing Repair area: adequate limited none available WATER SUPPLY Well casing 12" above ground yes no Well 100 ft from drainfield yes no Sanitary seal in place yes no Water sample taken yes no Sample results rnmments- A+JDate `�- - `� Time3%•3d�(� Environmental Health Special' LU � ' 10 This report does not constitute a guarantee, either written or implied, that the system will continue to function properly. This report constitutes a summary of findings only. O� Q H:Vmm U*=b%1wm9Uw.trm -\j �'e-c.S� A+JDate `�- - `� Time3%•3d�(� Environmental Health Special' LU � ' 10 This report does not constitute a guarantee, either written or implied, that the system will continue to function properly. This report constitutes a summary of findings only. O� Q H:Vmm U*=b%1wm9Uw.trm -\j ACTIVITY REPORT FILE NAME/NUMBER PARCEL # q t n qnn ADDRESS Health Department Staff: �r Y' G-, NARRATIVE: 01o,,, Actions: